Exam 4 - ARDS and Mechanical Ventilation

106. The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? *Select all that apply.* 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

*1. Altered level of consciousness is the earliest sign of hypoxemia.* 2. Urine output of less than 30 mL/hr indicates decreased cardiac output, which requires immediate intervention; it should be assessed every one or two hours, not once during a shift. *3. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two hours to prevent pressure ulcers.* *4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake.* *5. Fowler's position facilitates lung expansion and reduces the workload of breathing.*

107. Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one month to recuperate.

*1. Not smoking is vital to prevent further lung damage.* 2. The client should get vaccines to help prevent further episodes of serious respiratory distress. 3. Avoiding alcohol intake is appropriate for many serious illnesses, but it is not the most important when discussing ARDS. 4. It usually takes about six months to recover maximal respiratory function after ARDS.

99. The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

*1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.* 2. These are early signs of ARDS, but they could also indicate pneumonia, atelectasis, and other pulmonary complications, so they do not confirm the diagnosis of ARDS. 3. Clear breath sounds and the oxygen saturation indicate the client is not experiencing any respiratory difficulty or compromise. 4. These are signs of congestive heart failure; ARDS is noncardiogenic (without signs of cardiac involvement) pulmonary edema.

97. The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

*1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.* 2. The bed should be at a comfortable height for the UAP to bathe the client, not in the lowest position. 3. The UAP can bathe a client without assistance if the client's safety can be ensured. 4. The UAP is not ensuring the client's safety because the opposite side rail is not elevated to prevent the client from falling out of the bed.

102. The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

*1. These arterial blood gases are within normal limits, and therefore the nurse should not take any action except to continue to monitor the client.* 2. The nurse would recommend deep breaths and coughing if the client's ABGs revealed respiratory acidosis. 3. Sodium bicarbonate is administered when the client is in metabolic acidosis. 4. This is a normal ABG and the respiratory therapist does not need to be notified.

108. The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

*1. When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.* 2. The alarm may indicate the client needs suctioning, but the nurse should always do the least invasive procedure when troubleshooting a ventilator alarm. 3. The lip line on the ET tube determines how far the ET tube is in the trachea. It should always stay at the same number, but it would not have anything to do with the ventilator alarms. 4. This may be needed, but the nurse should not sedate the client unless absolutely necessary.

101. Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

1. A urine output of 30 mL/hr indicates the kidneys are functioning properly. 2. This indicates the client is being adequately oxygenated. *3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.* 4. An increased heart rate does not indicate a complication; this could result from numerous reasons, not specifically because of the ventilator.

103. The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

1. Alternating the ET tube position will help prevent a pressure ulcer on the client's tongue and mouth. 2. A CXR is performed immediately after insertion of the ET tube, but not daily. 3. The cuff should be inflated but no more than 25 cm H2O to ensure no air leakage, and must be checked every 4 to 8 hours, not daily. *4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one inch above the bifurcation of the bronchi.*

4. The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client? 1. Maintain the client's cardiac function. 2. Promote a continued decrease in lung surfactant. 3. Warm rapidly to minimize the effects of hypothermia. 4. Keep the oxygen saturation level above 93%.

1. An expected outcome is desired occurrence, not a common event. Tachycardia is a common manifestation of a near-drowning event, but it is not desired. A combination of physiological changes, hypothermia, and hypoxia put the client at risk for life-threatening cardiac rhythms. 2. Any near-drowning causes a decrease in alveolar surfactant, which results in alveolar collapse. A decrease in surfactant is not the desired outcome. 3. The client needs to be rewarmed slowly to reduce the influx of metabolites. These metabolites, including lactic acid, remain in the extremeties. *4. The oxygen level needs to be maintained greater than 93%. The client needs as much support as necessary for this. Mechanical ventilation with peak end-expiratory pressure (PEEP) and high oxygen levels may be needed to achieve this goal.*

98. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

1. Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is appropriate, but it is not the first intervention. 2. Making sure alarms are functioning properly is appropriate, but checking a machine is not priority. *3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.* 4. Monitoring laboratory results is an appropriate intervention for the client on a ventilator, but monitoring laboratory data is not the priority intervention.

6. The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? 1. The client's arterial blood gases are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

1. The client would have low arterial oxygen when developing ARDS. *2. Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea.* 3. As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retraction and use of accessory muscles. 4. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

105. The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

1. The nurse must first address the client's acute respiratory distress and then notify other members of the multidisciplinary team. *2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved.* 3. The nurse must first address the client's respiratory distress before requesting any laboratory data. 4. Assessment is not always priority. In this situation, the client is in obvious acute respiratory distress; therefore, the nurse needs to intervene to help the client breathe.

7. Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM? 1. pH 7.38, PaO2 94, PaCO2 44, HCO3 24 2. pH 7.46, PaO2 82, PaCO2 34, HCO3 22 3. pH 7.48, PaO2 59, PaCO2 30, HCO3 26 4. pH 7.33, PaO2 94, PaCO2 44, HCO3 20

1. This ABG is within normal limits and would not be expected in a client with ARDS. 2. These ABG levels indicate respiratory alkalosis, but the oxygen level is within normal limits and would not be expected in a client with ARDS. *3. ABGs initially show hypoxemia with a PaO2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS.* 4. This ABG is metabolic acidosis and would not be expected in a client with ARDS.

100. The client who smokes two packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

1. This is an incorrect statement. ARDS has multiple etiologies, such as hemorrhagic shock, septic shock, drug overdose, burns, and near-drowning. Many people with near-drowning do not develop ARDS. 2. The layperson may not know what the term alveoli means, and the near-drowning is the initial insult that caused the ARDS. *3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing.* 4. Smoking does not increase the risk of developing ARDS. The etiology is unknown, but an initial insult occurs 24 to 48 hours before the development of ARDS.

104. Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

1. Unless the initial insult is an infection, an aminoglycoside antibiotic would not be a medication the nurse would anticipate being ordered. *2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.* 3. A potassium cation, such as Kayexalate, helps remove potassium from the bloodstream in the gastrointestinal tract and would not be prescribed for a client with ARDS. 4. NSAIDs are under investigation for treating ARDS because they block the inflammatory response, but the nurse should not anticipate this being prescribed by the health-care provider.

51. The client in the intensive care unit (ICU) on a mechanical ventilator is bucking the ventilator, causing the alarms to sound, and is in respiratory distress. Which assessment data should the nurse obtain? *List in the order of priority.* 1. Assess the ventilator alarms. 2. Assess the client's pulse oximetry reading. 3. Assess the client's lung sounds. 4. Assess for symmetry of the client's chest expansion. 5. Assess the client's endotracheal tube for secretions.

In order of priority: 5, 2, 3, 4, 1 5. The most common cause of bucking the ventilator is obstructed airway, which could be secondary to secretions in the airway, so assessing the client would be most appropriate. 2. Clients in the ICU are constantly monitored by pulse oximetry; therefore, the nurse should determine if the client has decreased oxygen saturation and if so, the nurse should start to "bag" the client. The client is in respiratory distress. 3. The nurse should assess the client's lung fields to determine if air movement is occurring since the client is in respiratory distress. 4. A complication of mechanical ventilation is a pneumothorax, and the nurse should assess for this since the client is in respiratory distress. 1. The machine is alerting the nurse there is a problem with the client; since the client is in respiratory distress, the client should be assessed first. If the client were not in distress, then the nurse should assess the machine first to determine which alarm is sounding.